Lifestyle Assessment Form Adlerian PDF Details

The Lifestyle Assessment Adlerian form, as designed by prominent professionals Robert G. Bartholow, MSW, Robert G. Willhite, MSW, and Susan Pye Brokaw, MA from the Adler Graduate School, is a comprehensive tool that dives deep into an individual's early familial and personal milieu to unearth fundamental aspects of their psyche and behavioral patterns. This form meticulously covers a vast array of areas including, but not limited to, family constellation—which details family members and their dynamics, sexual and physical development, and a series of childhood to adult experiences ranging from dreams and fears to ambitions and early recollections. The assessment guides the completing individual through a reflective journey, asking them to consider various aspects of their upbringing, such as their perceptions of their parents, sibling relationships, and significant adult influences, along with pivotal developmental milestones and experiences. This structured yet introspective inquiry offers a detailed lens into the respondent's past, aiming to shed light on the underlying factors that influence their current lifestyle choices and psychological disposition. With its rich, detailed prompts and thoughtprovoking questions, the Adlerian form stands as a key instrument in understanding the complexity of human behavior and the varied paths that lead to adulthood, invoking a deep analysis of the self within the familial and social context.

QuestionAnswer
Form NameLifestyle Assessment Form Adlerian
Form Length17 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min 15 sec
Other namesadlerian lifestyle assessment, adlerian lifestyle assessment pdf, adler lifestyle assessment questionnaire, assessment form adlerian

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ADLER GRADUATE SCHOOL

 

Lifestyle Assessment

 

by Robert G. Bartholow, MSW, Robert G. Willhite, MSW, Susan Pye Brokaw,MA

 

 

Table of Contents

 

Table of Contents

1

I.

Family Constellation

2

A.

Members of your family of origin: (Enter Name of Your Mother and Father)

2

B.

Children (Include brothers and sisters and self, in order of birth. Also indicate

 

 

miscarriages, stillborn, and deceased siblings.)

2

C.

Data on client as a child:

3

D.

Sibling Interrelationships:

5

E.

Description of your parents, as seen by you when you were a child:

5

F.

Additional adult figures who had a significant influence on your childhood

9

II.

Sexual and Physical Development

9

A.

Sexual development:

9

B.

Physical Development:

10

III.

Childhood Dreams:

10

IV.

Childhood Fears:

10

V.

Childhood Ambitions:

10

VI.

Adult Dreams:

10

VII.

Three Wishes at This Point in Time

11

VIII.

Early Recollections

12

Summary Statements

13

© 2006 Adler Graduate School

May be reproduced in its original form as long as this copyright notice is included

Adler Graduate School

Lifestyle Assessment

Client’s Name

Date

Therapist

I.Family Constellation

A. Members of your family of origin:

Name

Father

 

Mother

 

 

 

B.Children (Include brothers and sisters and self, in order of birth. Also indicate miscarriages, stillborn, and deceased siblings.)

Insert Genogram below

Revised 1/2006

2

Adler Graduate School

Lifestyle Assessment

Give childhood descriptions of each child, in birth order, including self

Name

Brief Description

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.Data on client as a child:

1Who was most like you? In what ways?

2Who was most different from you?

In what ways?

3Grade school information: Attitude?

Favorite subject? Least liked subject? Social situation? Teachers pet?

4Sports interests or skills?

5Childhood habits?

6When a child, who had health problems, physical or emotional?

7*

As a child, did you feel

 

 

that boys or girls had

 

 

advantages over the

 

 

other?

 

 

 

Revised 1/2006

3

 

Adler Graduate School

 

 

 

 

 

Lifestyle Assessment

 

 

 

 

 

 

 

 

 

 

 

 

8*

If a female, were you a

 

 

 

 

 

 

 

tomboy in childhood?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9*

If male, did you personally

 

 

 

 

 

 

 

think of yourself as a

 

 

 

 

 

 

 

sissy?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10

Childhood spiritual or

 

 

 

 

 

 

 

religious experiences, if

 

 

 

 

 

 

 

any?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11

Did you, or any family

Emotional

 

Physical

 

Sexual

 

 

member(s), experience any

 

 

 

 

 

 

 

abuse (within or outside

 

 

 

 

 

 

 

the family)?

 

 

 

 

 

 

 

 

Yes

 

Yes

 

Yes

 

 

 

No

 

No

 

No

 

 

If so:

 

 

 

 

 

 

 

to whom?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

By whom?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Elaborate?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12

Who was most spoiled?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

By whom?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How and for what reason?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13

Who was most punished?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

By whom?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How and for what reason?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14

Who in the family needed

 

 

 

 

 

 

 

to be right?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15

Who in the family felt keen

 

 

 

 

 

 

 

about fairness and

 

 

 

 

 

 

 

unfairness?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16

Your role in peer group?

 

 

 

 

 

 

 

(leader, middler, follower,

 

 

 

 

 

 

 

outsider)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17

Childhood talents or

 

 

 

 

 

 

 

accomplishments?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18

Your parent’s method of

 

 

 

 

 

 

 

disciplining?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 1/2006

4

 

 

 

 

 

Adler Graduate School

Lifestyle Assessment

1

2

3

4

5

6

D.Sibling Interrelationships: Who took care of whom?

Who played with whom?

Who got along best with whom?

Who fought and argued most?

Who was helpful at home?

Who made mischief?

E.Description of your parents, as seen by you when you were a child:

FatherMother

Current age if living

If deceased

Age when client born

Education

Occupation

Personality: traits admired, liked, disliked, feared

What was most important to them?

What behavior or attitude could win their praise?

What made them angry?

What ways did they influence you?

What were their expectations of the children?

Revised 1/2006

5

Adler Graduate School

Lifestyle Assessment

Description of your parents, as seen by you when you were a child: (continued)

Father

Mother

Relationship with children?

Which child was most like them?

How?

Who were you closest to?

Were you distant from either?

Why?

In whom did you confide?

To whom did you go for comfort and support?

Why?

As a child, what kind of relationship did they have?

Who was dominant, made decisions, overt and covert?

Did they agree on discipline and raising the children?

Did they quarrel openly?

About What?

How did the quarrels end?

How did your parents solve problems

Other significant adults characteristics

Revised 1/2006

6

Adler Graduate School

Lifestyle Assessment

Considering your answers to the above what did you learn about: Yourself?

What males are like?

What females are like?

What marriage is like?

What parenting and family life is like?

Childhood Attributes

Using the table on the next page, rate (not rank) you and your siblings from your perspective as a child. Rank only yourself and siblings who are within 5 years older or younger than yourself. Put the name of each child including yourself (in birth order) - in the box above the column. Rate those who are (H) High or (L) Low

Revised 1/2006

7

Adler Graduate School

Lifestyle Assessment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Achieve-

ment &

Success

Intelligence

 

 

 

 

 

 

Successful

 

 

 

 

 

 

 

Grades

 

 

 

 

 

 

Helped at Home

 

 

 

 

 

 

 

Industrious

 

 

 

 

 

 

Looks

 

 

 

 

 

 

 

Stds. Achievement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Character-

 

Tried to Please

 

 

 

 

 

 

Moody

 

 

 

 

 

 

 

Special

istics

Succeeded Pleasing

 

 

 

 

 

 

Used Others

 

 

 

 

 

 

 

Considerate

 

 

 

 

 

 

Sociable

 

 

 

 

 

 

 

Tried to be Good

 

 

 

 

 

 

Sought Attention

 

 

 

 

 

 

 

 

 

Selfish

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Obedient

 

 

 

 

 

 

Critical of Others

 

 

 

 

 

 

 

Right-

Wrong

 

Openly Rebelled

 

 

 

 

 

 

Perfectionist

 

 

 

 

 

 

 

 

Covertly Rebelled

 

 

 

 

 

 

Tried to be Good

 

 

 

 

 

 

 

 

Stds. Right/Wrong

 

 

 

 

 

 

Mischievous

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Critical of Self

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assertive

 

 

 

 

 

 

Fighter-Scrappy

 

 

 

 

 

 

 

Interpersonal

Tendencies

 

Bossy-Dominating

 

 

 

 

 

 

Shy

 

 

 

 

 

 

 

 

Demanded Way

 

 

 

 

 

 

Sulked/Pouted

 

 

 

 

 

 

 

 

Got Way

 

 

 

 

 

 

Stubborn

 

 

 

 

 

 

 

 

Sense of Humor

 

 

 

 

 

 

Sensitive

 

 

 

 

 

 

 

 

Temper

 

 

 

 

 

 

Pitied self

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Competitive

 

 

 

 

 

 

Held Grudges

 

 

 

 

 

 

 

 

 

 

Idealistic

 

 

 

 

 

 

Self Confident

 

 

 

 

 

 

 

 

 

 

Materialistic

 

 

 

 

 

 

Insecure

 

 

 

 

 

 

 

 

 

 

Loner

 

 

 

 

 

 

Neat

 

 

 

 

 

 

 

 

Characteristics

 

Persistent

 

 

 

 

 

 

Gave Up Easily

 

 

 

 

 

 

 

Attitudes &

 

Excitement Seeker

 

 

 

 

 

 

Dependent

 

 

 

 

 

 

 

 

Daring

 

 

 

 

 

 

Independent

 

 

 

 

 

 

 

 

Complained

 

 

 

 

 

 

Easy Going

 

 

 

 

 

 

 

 

Responsible

 

 

 

 

 

 

Impulsive

 

 

 

 

 

 

 

 

Withdrawn

 

 

 

 

 

 

Cautious

 

 

 

 

 

 

 

 

 

 

Chip on Shoulder

 

 

 

 

 

 

Worrier

 

 

 

 

 

 

 

 

 

 

Punished

 

 

 

 

 

 

Self Esteem

 

 

 

 

 

 

 

 

 

 

Spoiled

 

 

 

 

 

 

Inferiority Flags

 

 

 

 

 

 

 

 

 

 

Pampered

 

 

 

 

 

 

Hid Feelings

 

 

 

 

 

 

 

Gender Charact-

eristics

 

Athletic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Masculine*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Feminine*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 1/2006

8

Adler Graduate School

Lifestyle Assessment

F.Additional adult figures who had a significant influence on your childhood

Who

Describe the

How did it influence you?

 

relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

II.Sexual and Physical Development

A. Sexual development:

1.When did you first notice your sexual development?

2.How did you feel about it?

3.Were you prepared for it?

4.If female - when did you first start menstruation? How did you feel about it?

Were you prepared for it?

Have you had any menstrual difficulties?

Have you had any prenatal or postnatal difficulties?

*5. If a boy, were you told you should have been a girl?

*6. If a girl, were you told you should have been a boy?

Revised 1/2006

9

Adler Graduate School

Lifestyle Assessment

7.Review all 7 starred (*) items for additional gender issues

8.As an adult have you experienced any sexual problems?

9.What is your sexual orientation: ‰ Heterosexual

‰Homosexual ‰ Bi-sexual

How do you feel about your orientation?

B.Physical Development:

1.Any childhood health problems?

If so, how were you treated by others?

2.How did you see your body image?

3.Did you have any disabilities?

III. Childhood Dreams:

IV. Childhood Fears:

V.What did you want to be when you grew up?:

VI. Current Aspirations:

Revised 1/2006

10

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Put the asked information in the Give childhood descriptions of, Brief Description, Data on client as a child, C Who was most like you, In what ways, and Who was most different from you In segment.

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Point out the main information about the Who was most different from you In, Grade school information Attitude, Favorite subject, Least liked subject, Social situation, Teachers pet, Sports interests or skills, Childhood habits, When a child who had health, and As a child did you feel that boys segment.

form adlerian Who was most different from you In, Grade school information Attitude, Favorite subject, Least liked subject, Social situation, Teachers pet, Sports interests or skills, Childhood habits, When a child who had health, and As a child did you feel that boys fields to fill out

The Adler Graduate School Lifestyle, Emotional, Physical, Sexual, Yes No, Yes No, Yes No, If a female were you a tomboy in, If male did you personally think, Childhood spiritual or religious, Did you or any family members, If so to whom, By whom, and Elaborate field will be your place to place the rights and responsibilities of all parties.

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Finalize by looking at all of these fields and filling in the proper information: Who was most spoiled, By whom, How and for what reason, Who was most punished, By whom, How and for what reason, Who in the family needed, to be right, Who in the family felt keen about, and Your role in peer group leader.

Who was most spoiled, By whom, How and for what reason, Who was most punished, By whom, How and for what reason, Who in the family needed, to be right, Who in the family felt keen about, and Your role in peer group leader in form adlerian

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